Country-level sociocultural context and socioeconomic inequalities in adolescent dietary behaviours: A multilevel analysis in 21 European countries.

Studies to date have predominantly focused on countries' socioeconomic conditions (e.g., income inequality) to explain cross-national differences in socioeconomic inequalities in adolescent health (behaviours). However, the potential explanatory role of sociocultural contexts at country-level remains underexamined. This study examined whether the country-level sociocultural context and changes thereof were associated with adolescent socioeconomic inequalities in dietary behaviours. International comparative data of 344,352 adolescents living in 21 countries participating in 2002, 2006, 2010 and 2014 waves of the Health Behaviour in School-aged Children (HBSC) survey were combined with aggregated levels of openness-to-change from the European Social Survey (ESS). Four dietary behaviours (i.e., fruit, vegetable, sweets and soft drink consumption) and two measures of socioeconomic status (SES) on the individual level (i.e., family affluence scale [FAS] and occupational social class [OSC]) were studied. Multilevel logistic regression analyses returned contrasting results for the two SES measures used. In countries with higher levels of openness-to-change, smaller FAS inequalities in daily fruit, sweets and soft drink consumption were observed, but no such inequalities were found for vegetable consumption. Conversely, in these countries, larger OSC inequalities in soft drink consumption were found. Country-specific changes in openness-to-change over time were not associated with the magnitude of adolescent dietary inequalities. Findings underscore the importance of including country-level sociocultural contexts to improve the understanding of cross-national differences in socioeconomic inequalities in adolescents' diets. Future studies, spanning a longer timeframe, are required to examine whether such associations exist within countries over time since our timeframe might have been too small to capture these long-term trends.

Trust matters: The Addressing Vaccine Hesitancy in Europe Study.

This article presents the design of a seven-country study focusing on childhood vaccines, Addressing Vaccine Hesitancy in Europe (VAX-TRUST), developed during the COVID-19 pandemic. The study consists of (a) situation analysis of vaccine hesitancy (examination of individual, socio-demographic and macro-level factors of vaccine hesitancy and analysis of media coverage on vaccines and vaccination and (b) participant observation and in-depth interviews of healthcare professionals and vaccine-hesitant parents. These analyses were used to design interventions aimed at increasing awareness on the complexity of vaccine hesitancy among healthcare professionals involved in discussing childhood vaccines with parents. We present the selection of countries and regions, the conceptual basis of the study, details of the data collection and the process of designing and evaluating the interventions, as well as the potential impact of the study. Laying out our research design serves as an example of how to translate complex public health issues into social scientific study and methods.

Individual, interpersonal, and organisational factors associated with discrimination in medical decisions affecting people with a migration background with mental health problems: the case of general practice.

OBJECTIVES: Although people with a migration background (MB) have more unmet mental health needs than the general population, patients with a MB are still underrepresented in mental health care services. Provider bias towards these patients has been evidenced repeatedly but its driving factors remain elusive. We assessed the moderating effect of the individual (e.g. age and ethnicity), interpersonal (e.g. healthcare provider trust), and organisational (e.g. perceived workload) factors on general practitioners (GPs) differential decision-making regarding diagnosis, treatment, and referral for a depressed patient with or without a MB. DESIGN: An experimental study was carried out in which GPs were shown one of two video vignettes featuring adult male depressed patients, one with a MB and the other without. Belgian GPs (n = 797, response rate was 13%) had to decide on their diagnosis, treatment, and referral. Analysis of variance and logistic regression were used to analyse the effect of a MB, adding interaction terms for the explanatory variables. RESULTS: Overall, we found that there were ethnic differences in GPs' decisions regarding diagnosis and treatment recommendations. GPs perceived the symptoms of the patient with a MB as less severe (F = 7.68, p < 0.01) and demonstrated a reduced likelihood to prescribe a combination of medical and non-medical treatments (F = 11.55, p < 0.001). Those differences increased in accordance with the GP's age and perceived workload; at an interpersonal level, we found that differences increased when the GP thought the patient was exaggerating his distress. CONCLUSION: This paper showed that lower levels of trust among GPs' towards their migrant patients and high GP workloads contribute to an increased ethnic bias in medical decision-making. This may perpetuate ethnic inequalities in mental health care. Future researchers should develop an intervention to decrease the ethnic inequities in mental health care by addressing GPs' trust in their migrant and ethnic minority patients.

'Through a kaleidoscope': A Foucauldian discourse analysis of Belgian policy regarding patients with a migration background and depression in general practices.

A higher prevalence of depression is found among patients with a migration background within the Belgian population. Nevertheless, this group is underrepresented in ambulant and residential mental health care services. Since general practitioners (GPs) have a crucial gatekeeping role, this led some researchers to investigate the possibility of a provider bias influencing GPs' assessment and referral of depressed patients with a migration background. However, GPs' accounts may be influenced by wider professional discourses present at the policy level, which are inevitably linked to institutions regulating the conduct of GPs. Therefore, this study applied a Foucauldian discourse analysis (a) to identify broader professional discourses in Belgian policy documents regarding patients with a migration background and depression in general practices, (b) to examine how patients with a migration background are discursively positioned and (c) to investigate which different balances of power in the relationship between GPs and patients with a migration background are demonstrated in the identified discourses. We identified three recurring discourses: (a) the othering discourse, (b) the health literacy discourse, and (c) the person-centred discourse. Our analysis demonstrated that the former two discourses illustrate the perpetuation of a biomedical discourse. While the last discourse is aligned with a counter-discourse associated with the person-centred care model in health care. Consequently, our analysis demonstrated the construction of a contradictory discursive framework throughout the various policy documents on which GPs might rely when speaking about patients with a migration background suffering from depression.

Migration-related inequalities in loneliness across age groups: a cross-national comparative study in Europe.

This study aims to contribute to the growing interest in the consequences of migration for loneliness by investigating the role of generational status across various age groups in countries with differing integration policies and attitudes towards immigrants. Using data from rounds 5, 6 and 7 of the European Social Survey, I conducted logistic multilevel models on a sample of 121,835 respondents aged 18 years and older, residing in 26 countries. Loneliness was assessed based on a single-item item question from the Center for Epidemiologic Studies of Depression scale. The findings suggest that individuals with a migration background are more likely to experience loneliness than those without. Within this group, I found that first-generation immigrants who arrived after the age of 18 are more vulnerable to loneliness than those who arrived earlier, although the latter still reported more loneliness than second-generation immigrants. Furthermore, migration-related inequalities in loneliness were greater among the youngest age group (18-34 years) and in countries with a more positive public stance towards immigrants. In sum, this study highlights the persistent challenges that migration poses for loneliness across generations and age groups, and emphasizes the need to extend research in this area beyond older adults. Moreover, it suggests that promoting a welcoming culture towards immigrants may have unintended consequences for loneliness gaps, but further research is needed to explain this observation.

Study design: The social wellbeing of newly-arrived adolescent migrants in reception education in Flanders (socNAMs).

AIMS: socNAMs provides a comprehensive and comparative dataset for researchers to identify how students' recent migration and their school setting relates to their social wellbeing, particularly regarding their feelings of loneliness. Results: This study design article delineates a quantitative cross-sectional research study (socNAMs) which successfully developed three questionnaires that were administered with unique and hard to reach populations, newly-arrived adolescent migrants (NAMs) and school staff offering reception education in Flanders, Belgium. METHODS: At the individual level, socNAMs collected information on: (1) socio-demographic variables of NAMs; (2) migration and family context; (3) social relationships; (4) school experiences; (5) self-perceived wellbeing (physical and social); and (6) experiences with discrimination. The questionnaire developed for NAMs is available in 16 languages. To gain a further understanding of the impact of the school environment on NAMs, socNAMs collected contextual information primarily concerning school social capital by including data collected from teachers and reception-class coordinators. The final sample included 1379 NAMs, 50 teachers and 26 reception-class coordinators, from 35 schools offering reception education. CONCLUSIONS: In this article, we present the rationale for this study, the methodology of sampling and recruitment, the development and content of the questionnaires, some preliminary descriptive results and the strengths and limitations of the study. Future empirical studies will address the research aims outlined in this protocol paper. In addition, we highlight the opportunities that the dataset provides for advancing research regarding the social wellbeing of NAMs in varying school and national contexts.

Trends in the use of benzodiazepine receptor agonists among working-age adults in Belgium from 2004 to 2018.

Introduction: The use of psychotropics, such as benzodiazepine receptor agonists (BzRAs), among working-age adults in Belgium has shown educational differences. However, it is unclear how work status plays a role in this relationship. Therefore, this research aims to investigate whether work status explains observed educational differences in BzRA use. In addition, considering medicalisation processes, where non-medical factors, such as work status, are increasingly associated with medical mental health care-seeking behavior, this research also aims to investigate whether work status explains observed educational differences in BzRA use, regardless of mental health status. Methods: Data are obtained from the Belgian Health Interview Survey (BHIS). Four successive waves are covered: 2004, 2008, 2013, and 2018. The weighted data represent a sample of 18,547 Belgian respondents aged 18 to 65 years old. Poisson regression models are used to analyze the research aims. Time evolutions are plotted using marginal means postestimation. Results: The average use of BzRAs shows a slight decline over the waves studied (2004 = 5.99, 2008 = 5.88, 2013 = 5.33, 2018 = 4.31). Educational and work status differences in BzRA use are observed, regardless of mental health status. Individuals with longer education report lower use compared to individuals with shorter education, and individuals who are unemployed, (pre-)retired, or sick or disabled report higher use compared to employed individuals. Furthermore, work status acts as a mediator, partially explaining educational differences in BzRA use, regardless of mental health status. Discussion: Work-related uncertainty leads to increased prescribing and medication use, regardless of mental health. Medicalisation and pharmaceuticalisation processes detach social problems from their social roots and treat them as personal failures. The marginalization of the social roots of unemployment, sick leave and involuntary (pre-)retirement has led to a personalization of responsibility. Negative feelings arising from such work statuses may cause isolated, non-specific symptoms for which medical treatment is sought.

Unintentional Discrimination Against Patients with a Migration Background by General Practitioners in Mental Health Management: An Experimental Study.

Populations with a migration background have a higher prevalence of mental health problems than their native counterparts. They are also more likely to have unmet medical needs and are less frequently referred to mental health services. One potential explanation for this is that physicians, such as general practitioners (GPs), may unintentionally discriminate against migrant patients, particularly when they lack humanization. To date, no experimental study has investigated this hypothesis. This paper assesses the influence of humanization on GPs' discriminatory decisions regarding migrant patients with depression. A balanced 2 × 2 factorial experiment was carried out with Belgian GPs (N = 797) who received video-vignettes depicting either a native patient or a migrant patient with depression. Half of the respondents were exposed to a text that humanized the patient by providing more details about the patient's life story. Decisions related to diagnosis, treatment and referral were collected, as well as the time spent on each video and text, and were analysed using ANOVA. Migrant patients' symptoms were judged to be less severe than those of native patients (F = 7.71, p < 0.05). For almost all treatments, the decision was less favourable for the migrant patient. Humanization had little effect on medical decisions. We observed that GPs spent significantly more time on the vignette with the humanization intervention, especially for the migrant patients. The results indicate that ethnic differences in the management of depression persist in primary care. Humanization, however, does not mitigate those differences in medical decisions.

Marital-history differences in increased loneliness during the COVID-19 pandemic: A European study among older adults living alone.

The COVID-19 pandemic and related physical distancing measures have disproportionally affected older adults living alone due to their greater social isolation. Unlike previous studies on the subject, the current research recognizes the diversity amongst older adults living alone by considering the impact of marital history. Combining information from Wave 8 of the Survey of Health Ageing and Retirement (SHARE), with data of SHARELIFE and the SHARE Corona survey, we investigated the differential impact of the COVID-19 pandemic on loneliness in older men (N = 1504) and women (N = 4822) living alone. Logistic multilevel analyses were performed on data from 26 European countries and Israel. For men, we found that the short-term widowed were more likely to report increased loneliness than the medium- and long-term widowed and those living apart together (LAT). For women, the results indicated that the short- and medium-term widowed and the divorced were at greater risk for increased loneliness than those in a LAT relationship. Also, medium-term widowed women were more likely to report increased loneliness than their long-term widowed counterparts. The three hypothesized underlying mechanisms - i.e., (i) the opportunity mechanism, (ii) the expectation mechanism, and (iii) the vulnerability mechanism - only played a small role in explaining the observed differences. In sum, our study highlights the importance of recognizing the diversity within the group of older adults living alone when investigating the effects of the pandemic on loneliness, yet the mechanisms behind the stratifying role of marital history are not fully understood.

Socioeconomic inequalities in adolescent health behaviours across 32 different countries - The role of country-level social mobility.

Higher family affluence is associated with healthier behaviours in adolescents, but the strength of this association varies across countries. Differences in social mobility at the country-level, i.e. the extent to which adolescents develop a different socioeconomic status (SES) than their parents, may partially explain why the association between family affluence and adolescent health behaviours is stronger in some countries than in others. Using data from adolescents aged 11-15 years from 32 countries, participating in the 2017/2018 wave of the Health Behaviour in School-aged Children (HBSC) study (N = 185,086), we employed multilevel regression models with cross-level interactions to examine whether country-level social mobility moderates the association between family affluence and adolescent health behaviours (i.e. moderate-to-vigorous physical activity, vigorous physical activity, healthy and unhealthy foods consumption, having breakfast regularly, and weekly smoking). Higher family affluence was more strongly associated with higher levels of adolescent physical activity in countries characterized by high levels of social mobility. No cross-level interactions were found for any of the other health behaviours. Differences in social mobility at the country-level may contribute to cross-national variations in socioeconomic inequalities in adolescent physical activity. Further research can shed light on the mechanisms linking country-level social mobility to inequalities in adolescent physical activity to identify targets for policy and interventions.

Mind the Gate: General Practitioner's Attitudes Towards Depressed Patients with Diverse Migration Backgrounds.

This study aims to examine (a) whether there are differences in general practitioners' (GPs) attitudes towards native Belgian patients, patients of foreign descent and asylum seeking patients who all express symptoms of major depression, and (b) whether these differences depend on GPs' experience with cultural competency training and interethnic contact. Using a video vignette study among 404 Flemish (Belgium) GPs, we find evidence of a provider bias. While GPs regard a patient of foreign descent as less trustworthy and less able to adhere to medical recommendations than a native Belgian patient, they also hold more pessimistic views on a potential recovery of an asylum seeking patient. In addition, we find that cultural competency training might alter GPs' attitudes of asylum seeking patients in a positive way. Summarized, our research highlights the need to target stereotypes among GPs for interventions designed to reduce migration-based disparities in healthcare use and health status.

Perceived Social Support from Different Sources and Adolescent Life Satisfaction Across 42 Countries/Regions: The Moderating Role of National-Level Generalized Trust.

Although previous research established a positive association between perceived social support and adolescent life satisfaction, little is known about the relative importance of different sources of support for adolescent life satisfaction and cross-country variations in this respect. Using large-scale representative samples from the 2017/18 Health Behaviour in School-aged Children (HBSC) study, this study examined to what extent the association between social support and life satisfaction in early adolescence varied across different social sources and countries. Also, it examined whether cross-country variations are explained by national-level generalized trust, a sociocultural factor that shapes adolescent socialization. National-level data were linked to data from 183,918 early adolescents (Mage = 13.56, SD = 1.63, 52% girls) from 42 European and North American countries/regions obtained from HBSC. Multilevel regression analyses yielded a positive association between support from different sources and life satisfaction. The strongest associations were found for support from families, followed by teachers and classmates, and weakest for support from friends. Associations varied across different countries/regions. National-level trust amplified the association between perceived classmate support and adolescent life satisfaction. The revealed cross-country differences open avenues for future cross-cultural research on explanations for cross-cultural differences in the association between social support from different sources and life satisfaction in early adolescence.

Mental Health in Adolescents with a Migration Background in 29 European Countries: The Buffering Role of Social Capital.

Previous research is inconclusive as to whether having an immigration background acts as a risk factor for poor mental health in adolescents, and furthermore, what contribution the social context in which adolescents grow up may make. To address these questions, the current study uses an integrative resilience framework to investigate the association between immigration background and adolescent mental health, and the moderating role of social capital at the individual, the school, and the national level. The study uses data gathered from nationally representative samples of adolescents aged 11, 13, and 15 years (Ngirls = 63,425 (52.1%); Mage = 13.57, SD = 1.64) from 29 countries participating in the 2017/18 Health Behaviour in School-aged Children (HBSC) study. Data analysis reveals that first- and second-generation immigrants reported higher levels of life dissatisfaction and psychosomatic symptoms than their native peers, and that this association varied across schools and countries. In addition, social capital was found to moderate the association between immigration background and adolescent mental health. Individual-level social support from peers and family and national-level trust protected against poor mental health in adolescents with an immigration background, while the opposite was true for individual-level teacher support. Supportive teacher-student relationships were found to provide more protection against poor mental health for native adolescents than for immigrant adolescents. Our findings indicate the importance of taking an ecological approach to design interventions to reduce the negative effects of having an immigration background on adolescent mental health.

Country-Level Meritocratic Beliefs Moderate the Social Gradient in Adolescent Mental Health: A Multilevel Study in 30 European Countries.

PURPOSE: Adolescents with higher socioeconomic status (SES) report better mental health. The strength of the association-the "social gradient in adolescent mental health"-varies across countries, with stronger associations in countries with greater income inequality. Country-level meritocratic beliefs (beliefs that people get what they deserve) may also strengthen the social gradient in adolescent mental health; higher SES may be more strongly linked to adolescent's perceptions of capability and respectful treatment. METHODS: Using data from 11-15 year olds across 30 European countries participating in the 2013/2014 Health Behaviour in School-aged Children study (n = 131,101), multilevel regression models with cross-level interactions examined whether country-level meritocratic beliefs moderated the association between two individual-level indicators of SES, family affluence and perceived family wealth, and three indicators of adolescent mental health (life satisfaction, psychosomatic complaints, and aggressive behavior). RESULTS: For family affluence, in some countries, there was a social gradient in adolescent mental health, but in others the social gradient was absent or reversed. For perceived family wealth, there was a social gradient in adolescent life satisfaction and psychosomatic complaints in all countries. Country-level meritocratic beliefs moderated associations between SES and both life satisfaction and psychosomatic complaints: in countries with stronger meritocratic beliefs associations with family affluence strengthened, while associations with perceived family wealth weakened. CONCLUSIONS: Country-level meritocratic beliefs moderate the associations between SES and adolescent mental health, with contrasting results for two different SES measures. Further understanding of the mechanisms connecting meritocratic beliefs, SES, and adolescent mental health is warranted.

Adolescents' sleep quality in relation to peer, family and school factors: findings from the 2017/2018 HBSC study in Flanders.

PURPOSE: While a multitude of studies focused on biological and behavioral determinants of adolescents' sleep quality, a paucity of research examined the impact of social factors. The current study therefore examines the relationship between adolescents' sleep quality and peer, family and school factors. METHODS: Data of Flemish participants in the 2017/2018 Health Behavior in School-aged Children survey (HBSC) were used, which is representative of the adolescent population (11-18 years) in Flanders. Adolescents' sleep quality was linked to individual-level data on peer relationships (i.e., peer support), family relationships (i.e., family support, perceived family wealth, caregiving responsibilities) and school relationships (i.e., teacher support, school support, school pressure) and contextual-level data on the school culture. Three-level multilevel models were fitted to account for the clustering of individuals (N = 8153) within classes (N = 769) and classes within schools (N = 177). RESULTS: The individual-level results indicated that adolescents' sleep quality was positively related to family support, teacher support, student support and perceived family wealth. In contrast, adolescents' sleep quality was negatively related to caregiving responsibilities and school pressure. In addition, the contextual-level results pointed out that adolescents tended to report better sleep quality in less-demanding schools. CONCLUSION: These findings highlight the need to consider social factors in promoting better sleep in adolescence.

Perceived group discrimination based on one's gender and the gender gap in depression in Europe.

BACKGROUND: Gender discrimination is one of the most significant psychosocial stressors. This study examined whether the relationship between perceived group discrimination against one's gender (PGD) and the gender gap depression varied by societal levels of gender inequality. METHODS: The current study used data from three waves (2006, 2012 and 2014) of the European Social Survey and applied multilevel linear regression methods. We assessed depressive feelings through the eight-item version of the Centre for Epidemiological Studies Depression Scale. The sample contained 71,419 respondents living in 22 countries. RESULTS: While only a small percentage of people were confronted with PGD, this group consistently reported more depressive feelings. PGD had a similar effect on the mental health of men and women, except for men in more gender-egalitarian societies. When confronted with PGD, the latter group reported more depressive feelings in comparison to men in more gender unequal societies. CONCLUSIONS: Our research found a strong association between PGD and depression. In addition, this relationship varied by societal levels of gender equality. More pronounced gender equality strengthened this relationship in men. Research that ignores this social context might, therefore, be limited in terms of generalization.

Burdens in mental health recovery: Causal beliefs and their relation to stigma and help seeking recommendations.

BACKGROUND: Lay attitudes are often seen as potential barriers to mental health recovery. But apart from perceiving them as potential barriers, they can also play an important role in stimulating individuals to consult (in)formal help sources, in particular through the process of help referral. Where existing research mainly focusses on actual help seeking behaviour, this study will focus on lay publics' referral behaviour. AIMS: This study analyses the relation between causal beliefs and stigmatising attitudes and social distance on the one hand, and (in)formal help seeking recommendations on the other. METHODS: Data from a survey carried out in 2019, assessing the attitudes of Public Health Insurance Provider (HIP) members towards mental health problems, was used. Part of the survey questions was based on a quantitative quasi-experimental design, using hypothetical written vignettes. The weighted data represent a sample of the adult Flemish population (22-94 years, N = 5675). Multiple linear regression analysis was used to examine the relation between causal beliefs and stigma, while binominal logistic regression analysis was used to investigate the relation between causal beliefs and help seeking recommendations. RESULTS: The results reveal that causal beliefs significantly associate with stigma, measured by stigmatising attitudes and social distance: personal- or biogenetic beliefs associate with more stigma, where psychosocial beliefs associate with less stigma. Concerning help seeking recommendations, psychosocial beliefs associate with recommending psychological or psychotherapeutic care, biogenetic beliefs associate with advising help from general practitioners and suggesting psychiatric help, while personal beliefs negatively associate with recommending formal help. Meanwhile, biogenetic beliefs associate with less informal help seeking recommendations (e.g. family, friends and online self-help), where personal beliefs associate with more informal help seeking recommendations and psychosocial beliefs only associate with online help referral. CONCLUSION: This study highlights the importance of causal beliefs in affecting public stigma and help seeking recommendations.

Depression in women and men, cumulative disadvantage and gender inequality in 29 European countries.

Macro-sociological theories stress the contribution of gender inequality to this gender gap in depression, while cumulative advantage/disadvantage theory (CAD) reminds us that mental health inequalities accumulate over the life course. We explore the complementarity of both perspectives in a variety of European countries using data of the European Social Survey (2006 2012, 2014, N of countries = 29; N of men = 53,680 and N of women = 63,103) and using an 8-item version of the CES-D. Results confirm that the relevance of gender stratification for the mental health of women and men in Europe depends on age. The gender gap is nearly absent amongst adults in their twenties in the most gender equal countries, while an impressive gender gap is present amongst older adults in gender unequal countries, in accordance with CAD theory. These effects occur on top of the mental health consequences of taking up work and family roles at various life stages. The convergence of the results predicted by gender stratification and cumulative disadvantage theories strengthen the case for the link between gender, disadvantage and depression.

Do comprehensive school reforms impact the health of early school leavers? Results of a comparative difference-in-difference design.

In the current article, we examine whether and how reforms in tracking age affect educational inequalities in health among people between the ages of 25-75 years. Particular attention is paid to the health consequences for early school leavers. The study combines data from the European Social Survey (2002-2016) on 21 countries with country-cohort information on education policies. Moreover, a difference-in-difference design is used, which takes advantage of both the cross-national and cross-temporal variability in the implementation of comprehensive schooling reforms. The results reveal statistically significant, but very small effects of de-tracking policies on people's health. That is, comprehensive education leads to slight improvements in health among people who have attained upper secondary or tertiary education, but these improvements are achieved at the expense of the health of those with the lowest levels of education. Our study should encourage future research to further explore the institutional impact of educational systems on the health of individuals.